Sandbox:AHAPrince

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Clinical Risk Factors

Valvular Heart Disease

Class I

"1. It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation(Level of Evidence: C)"

"2. . For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk(Level of Evidence: C)"

Class IIa

"1. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis (Level of Evidence: B)"

"2. . Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe MR (Level of Evidence: C)"

"3. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe aortic regurgitation and a normal left ventricular ejection fraction (Level of Evidence: C)"

Class IIb

"1. . Elevated-risk elective noncardiac surgery using appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable in asymptomatic patients with severe mitral stenosis if valve morphology is not favorable for percutaneous mitral balloon commissurotomy. (Level of Evidence: C)"

Other clinical risk factors

Class I

"1. Before elective surgery in a patient with a CIED, the surgical/procedure team and clinician following the CIED should communicate in advance to plan perioperative management of the CIED.(Level of Evidence: C)"

"2.Chronic pulmonary vascular targeted therapy (i.e., phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, and prostanoids) should be continued unless contraindicated or not tolerated in patients with pulmonary hypertension who are undergoing noncardiac surgery.(Level of Evidence: C)"

Class IIa

"1. Unless the risks of delay outweigh the potential benefits, preoperative evaluation by a pulmonary hypertension specialist before noncardiac surgery can be beneficial for patients with pulmonary hypertension, particularly for those with features of increased perioperative risk (Level of Evidence: C)"

Approach to perioperative cardiac testing

Multivariate risk indices

Class IIa

"1. A validated risk-prediction tool can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery (Level of Evidence: B)"

Class III (No Benefit)

"1.For patients with a low risk of perioperative MACE, further testing is not recommended before the planned operation (Level of Evidence: B)"

Supplemental preoperative evaluation

The 12-Lead Electrocardiogram

Class IIa

"1. . Preoperative resting 12-lead electrocardiogram (ECG) is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery (Level of Evidence: B)"

Class IIb

"1. Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery (Level of Evidence: B)"

Class III (No Benefit)

"1. Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures (Level of Evidence: B)"

Assessment of Left Ventricular Function

Class IIa

"1. . It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of left ventricular (LV) function (Level of Evidence: C)"

"2. It is reasonable for patients with heart failure (HF) with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function. (Level of Evidence: C)"

Class IIb

"1. Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if there has been no assessment within a year (Level of Evidence: C)"

Class III (No Benefit)

"1. Routine preoperative evaluation of LV function is not recommended (Level of Evidence: B)"

Exercise Testing

Class IIa

"1. . For patients with elevated risk and excellent (>10 metabolic equivalents [METs]) functional capacity, it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery (Level of Evidence: B)"

Class IIb

"1. For patients with elevated risk and unknown functional capacity, it may be reasonable to perform exercise testing to assess for functional capacity if it will change management (Level of Evidence: B)"

"2. Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown (Level of Evidence: B)"

"3. For patients with elevated risk and moderate to good ($4 METs to 10 METs) functional capacity, it may be reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery (Level of Evidence: B)"

"4. For patients with elevated risk and poor (<4 METs) or unknown functional capacity, it may be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia if it will change management (Level of Evidence: C)"

Class III (No Benefit)

"1. Routine screening with noninvasive stress testing is not useful for patients at low risk for noncardiac surgery (Level of Evidence: C)"

Noninvasive Pharmacological Stress Testing Before Noncardiac Surgery

Class IIa

"1. . It is reasonable for patients who are at an elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo noninvasive pharmacological stress testing (either dobutamine stress echocardiogram or pharmacological stress myocardial perfusion imaging) if it will change management (Level of Evidence: B)"

Class III (No Benefit)

"1. . Routine screening with noninvasive stress testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence: B)"

Preoperative Coronary Angiography

Class III (No Benefit)

"1. Routine preoperative coronary angiography is not recommended. (Level of Evidence: C)"

Perioperative therapy

Coronary Revascularization Before Noncardiac Surgery

Class I

"1. 1. Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs(Level of Evidence: C)"

Class III (No Benefit)

"1. . It is not recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events (Level of Evidence: B)"

Timing of Elective Noncardiac Surgery in Patients With Previous PCI

Class I

"1. . Elective noncardiac surgery should be delayed 14 days after balloon angioplasty(Level of Evidence: C) and 30 days after BMS implantation(Level of Evidence: B)"

"2.Elective noncardiac surgery should optimally be delayed 365 days after drug-eluting stent (DES) implantation(Level of Evidence: B)"

Class IIa

"1. In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful (Level of Evidence: C)"

Class IIb

"1. Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis (Level of Evidence: B)"

Class III (Harm)

"1. Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom dual antiplatelet therapy will need to be discontinued perioperatively (Level of Evidence: B)"

"2. Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively. (Level of Evidence: C)"

Perioperative Beta-Blocker Therapy

Class I

"1. Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically(Level of Evidence: B)"

Class IIa

"1. It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started (Level of Evidence: B)"

Class IIb

"1. . In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers (Level of Evidence: C)"

"2. In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, coronary artery disease, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery (Level of Evidence: B)"

"3. In patients with a compelling long-term indication for betablocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit (Level of Evidence: B)"

"4. In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery ( (Level of Evidence: B)"

Class III (Harm)

"1. Beta-blocker therapy should not be started on the day of surgery (Level of Evidence: B)"

Perioperative Statin Therapy

Class I

"1. Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery(Level of Evidence: B)"

Class IIa

"1. Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery (Level of Evidence: B)"

Class IIb

"1. Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures (Level of Evidence: C)"

Alpha-2 Agonists

Class III (No Benefit)

"1. . Alpha-2 agonists for prevention of cardiac events are not recommended in patients who are undergoing noncardiac surgery (Level of Evidence: B)"

Angiotensin-Converting Enzyme Inhibitors

Class IIa

"1. Continuation of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers perioperatively is reasonable (Level of Evidence: B)"

"2. If angiotensin-converting enzyme inhibitors or angiotensinreceptor blockers are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively (Level of Evidence: C)"

Antiplatelet Agents

Class I

"1.. In patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES implantation, dual antiplatelet therapy should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis(Level of Evidence: C)"

"2. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor–inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor–inhibitor be restarted as soon as possible after surgery.(Level of Evidence: C)"

"3. Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis. (Level of Evidence: C)"

Class IIb

"1. In patients undergoing nonemergency/nonurgent noncardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased bleeding (Level of Evidence: B)"

Class III (No Benefit)

"1. Initiation or continuation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting (143) (Level of Evidence: B), unless the risk of ischemic events outweighs the risk of surgical bleeding (Level of Evidence: C)"

Perioperative Management of Patients With CIEDs

Class I

"1. Patients with implantable cardioverter-defibrillators who have preoperative reprogramming to inactivate tachytherapy should be on cardiac monitoring continuously during the entire period of inactivation, and external defibrillation equipment should be readily available. Systems should be in place to ensure that implantable cardioverter-defibrillators are reprogrammed to active therapy before discontinuation of cardiac monitoring and discharge from the facility(Level of Evidence: C)"